Less Pain, Fewer Pills – A Fibromyalgia Review: Part I

Seeking to curb their misuse, the FDA has come down hard on opioid painkillers, restricting their use, and making it more difficult for some people in chronic pain to gain access to them. Some fibromyalgia patients and their doctors have, not surprisingly, rebelled at the thought of a major source of pain relief disappearing.

Beth Darnall, PhD, believes there’s a better way. A pain psychologist from Stanford University, Darnell, who’s spent the past 15 years treating people with chronic pain, believes most chronic pain patients have missed better ways of dealing with pain. She’s written two books focused on reducing painkiller use, and has published over 50 articles in medical journals.

Darnall also personally knows of what she writes. Her wrenching, unexplained stomach pain had occurred for as long as she could remember. Despite being a competitive athlete and socially engaged, Beth periodically had to retreat to a quiet room to recover from the stabbing stomach pains that came and went without rhyme or reason.

Her boyfriend’s death while she was away at college brought her stomach pain to a new level, and for the first time, she sought help – at an emergency room where she was given Vicodin. The drug reduced her pain and brought her a “soothing numbness” she found helpful. Aided by her doctor, she began taking more of the drug, but after about 8 months dropped it, citing how spacey and passive she was becoming. (She now believes the excruciating stomach pains were the result of irritable bowel syndrome and stress.)

First Darnall describes “The Problem” – poor pain education and treatments that have led to an over-emphasis on opioid pain drugs, increased pain overall, and a societal problem with opioid drug abuse. Darnall isn’t a blanket opioid detractor – she says opioid drugs can be one part of a patient’s pain care program- but her emphasis in the first part of this book consists of highlighting the dangers and costs of over-prescribing opioids.

Opioid painkillers like Vicodin, Norco, etc. certainly have an important role in treating short-term pain, but there’s no denying that they’re over-prescribed in the U.S. Darnall notes that the U.S. consumes 80 percent of the entire world’s supply of opioids. In 2010 enough opioid prescriptions were sold to supply every adult in the U.S. with hydrocodone for a month. Opioid prescriptions and deaths from overdoses increased so much that the FDA has created much stricter guidelines regarding prescription use.

How did this happen? Darnall gives physicians something of a break in their role in creating the “opioid epidemic” currently sweeping the U.S. How can they effectively treat something, she asks, they’ve never been trained in?

As late as 2011, she reports, fewer than 4% of medical schools in the U.S. required that medical students take a pain course. Only 20% of medical schools even offered a pain course as an elective (!), and Darnall’s emphasis – the psychology of pain – which she calls “a critical aspect of chronic pain” – is hardly taught at all.

When doctors do learn about treating pain, they often learn about how to prescribe, police and monitor the use of opioid drugs in order to catch addicts or protect themselves legally. Few have any idea of how to manage or treat pain without the use of opioid drugs. Many prescribe opioid drugs for types of pain they’re not suited for. It’s clear that medical schools have failed both doctors and patients with regard to pain care.

Plus, deceptive advertising by pharmaceutical companies led many doctors to believe opioids were effective treatments for both short-term and chronic pain. Opioids are quite effective in treating short-term pain but are rarely very effective in treating chronic pain. (They can be quite effective in chronic pain but only for a minority of patients.)

The early short-term studies failed to uncover the problematic effects of long-term use. Excluding people with anxiety or depression – common outcomes of being in chronic pain – from opioid drug studies further negated their usefulness. Remarkably, given the number of Americans using opioids for long periods, it was only in 2013 that the FDA started requiring longer-term studies on some opioid drugs (extended-release).

Opioid drugs work best during the so-called “honeymoon” period in the first 6-8 weeks they’re used. After that, tolerance – which requires higher doses to be used to get the same result – begins to loom. Besides tolerance, a variety of side effects that have largely been discounted by the drug companies can result. Darnall asserts that few patients are made aware of the possible ramifications of longer term opioid use, or that the best opioids generally do is reduce pain by 25%.

Darnall actually states that tolerance – needing more drugs to get the same amount of pain relief – is inevitable if opioids are used long term. (“Tolerance is a natural, inevitable physiological consequence that every patient experiences.”) She also states that “for the average person taking opioids long term, the opioids become less effective over time.”

If you’re a man, long term opioid use may lead to low testosterone (causing irritability, low libido, erectile dysfunction, lethargy), problems with neurotransmitters, increased inflammation and more.

If you’re a woman, long term opioid use may lead to infertility/loss of the menstrual cycle (while on the drug), reduced hormone levels (low testosterone, estradiol, DHEA, lutenizing and follicular stimulating hormones), sleep problems, depression, reduced libido, inflammation and increased pain and a modest increased risk of some birth defects.

A Pharmaceutical Soup

A particularly difficult situation – which Darnall says she sees frequently – occurs when opioid drugs cause problems like anxiety and poor sleep which then lead to more drug use, leaving pain patients awash in what Darnall calls a “pharmaceutical soup.”

Take Tim’s case. After Tim laid his motorcycle down while going 60 mph, he required three back surgeries. Given his injuries and his long recovery period, he needed significant pain relief and he got it. Eighteen months later, though, still on high doses of opioids, he was irritable, depressed, suicidal and in pain. Testing revealed low testosterone levels. A slow taper of the opioids, increasing his testosterone level,s and the use of Darnall’s “personal empowerment plan” (described in the second half of the book) left him able to finally sleep, alleviated his depression, and increased his functionality. He still has pain but is now completely off opioids.

Opioids and Fibromyalgia

Tramadol, a less addictive and potent opioid than drugs like morphine, fentanyl and Vicodin, is probably the most commonly opioid drug used in fibromyalgia. A study (see below) bears out the fact that Tramadol, which is similar to codeine, has fewer side-effects than other opioids. Drugs.com reports, though, that while Tramadol is “well tolerated” with regards to pain, it, like other opioid drugs, can also cause common and serious side-effects.

A large (n=1700), long-term (year-long) fibromyalgia study suggested, that opioid painkillers may not be the best choice for FM patients. The study, which compared FM patients taking stronger opioid painkillers with those taking tramadol or no opioids or tramadol found that all groups reduced their pain levels over the year but that those not taking opioids made the most progress. Significantly, greater improvements in pain, functioning, depression, insomnia and disability were seen in either the tramadol or the no-drug group. The study concluded that “Overall, the findings show little support for the long-term use of opioid medications in patients with fibromyalgia given the poorer outcomes across multiple assessment domains associated with this cohort.”

Another study found that about 2/3rds of FM patients reported that opioids were “very effective” at reducing their pain but that those taking opioids for longer periods were more likely to be in more pain. FM patients were also less likely to discontinue opioids than other patients because of improvements in pain and more likely to report adverse experiences. Another earlier review acknowledged that opioid painkillers are commonly used in FM but “found no evidence from clinical trials that opioids are effective for the treatment of FM.”

Finally, a Mayo study indicated that FM patients undergoing an opioid taper program had significant improvements in pain scores, depression, catastrophizing, health perception, interference with life, and perceived life control.

Darnall reported on the experience of a fibromyalgia patient named Joan. The opioids Joan was prescribed for fibromyalgia and low back pain helped at first, but over time she required higher and higher doses to get the same effect. By the time she got to Darnall’s office, she was taking two opioids around the clock and suffering from numerous side effects including memory problems, severe fatigue and pain, and difficulty standing and walking. Not surprisingly, she was also depressed – for which she was given another prescription.

A very slow (5 month) opioid taper that got her off opioids eliminated her depression, gave her her brain back (she said opioids robbed her of her memory and her sharp thinking), improved her sleep, and surprise of surprises, reduced her pain levels.

In Chapter 4, Darnall lists a variety of unexpected opioid pitfalls that less wary opioid users can fall into. They include trading pain relief for a loss of functionality, overlooking opioids as the cause of new symptoms such as anxiety, depression, and poor sleep, using opioids to manage anxiety, using opioids to treat the wrong kinds of pain (such as neuropathic pain), and worsened pain over time and others.

The Solution

Darnall effectively communicates the potential downsides of using opioids to treat chronic pain in the first half of her short book. The meat of the book, though, lies in the second half titled “Your Solution is to Gain Control.”

Darnall doesn’t promise an end to chronic pain (she acknowledges that some pain cannot be fixed) but does promise to provide a way to manage pain which will relieve suffering, reduce one’s dependence on drugs and increase one’s functionality. How she proposes to do that is up next.About the Author: ProHealth is pleased to share information from Cort Johnson. Cort has had myalgic encephalomyelitis /chronic fatigue syndrome for over 30 years. The founder of Phoenix Rising and Health Rising, he has contributed hundreds of blogs on chronic fatigue syndrome, fibromyalgia and their allied disorders over the past 10 years. Find more of Cort's and other bloggers' work at Health Rising.

Darnell states that hydrocodone presents a patient with a "honeymoon period". If this is the case, then mine has lasted 25 years! The only reason I could have a career in medical science and clinical trials is because I had effective pain relief and could concentrate on my work.

Fibromyalgia is only 1 of my chronic pain medical conditions -a result of a number of medical conditions that were blown off by the medical community for so many years that they eventually developed into irreparable damage to body and mind. I was labelled an "attention seeker" and clinical sociopath by doctors who didn't even bother to examine me for skeletal and neurological defects caused by subclinical polio as an infant. The resulting stress from age 5 to well beyond age 40 were the probable inducers of fibromyalgia along with the defects themselves. Eventually their ignorance and cruelty resulted in multiple joint replacements and degenerative spinal OA.

Darnell is just another apologist for "alternative" pain management strategies with limited efficacy that few can afford. The review tendered makes one think she is bucking for an iron rice bowl with the CDC or HHS. The dog-whistle claim of clinical trials proving little to no efficacy for chronic pain control of FM with opioids neglects the fact that MANY of the trials had flawed methodology based on biased surveys. Or the alternative treatments presented were so inaccessible to typical patients on SSD that presenting them was an act of cruelty on the same level as "let them eat cake". Researchers in chronic pain know which side their bread is buttered on and behave accordingly.So does Darnell.

If you have been on a stable controlled modest pain management regimen that includes opioids, DON'T READ THIS BOOK! It will only make you feel guilty for using a proven and effective method that allows you to live a quality life and be a productive member of society.

You are quite right in criticizing the anti-opiate lobby. This comes at a time when so-called "personalized" medicine is on the rise. So it is a contradiction. Fibromyalgia is a heterogeneous syndrome caused by many different underlying conditions. Too often, when an FM diagnosis is made the patient is pigeon-holed. This is indeed dangerous. Similarly to atack opiate medication for FM in this way is wrong. Yes, opiates are of little help for some but very significant effect for other. Similarly, some people develop tolerance but others do not. I know of two people who have been on the same moderate dose of DHC (dihydro-codiene)for over 10 years with no problem or rise in pain.

In my work I have seen so many people with spinal pathology and FM co-pathology. Also there are those who's initial "diagnosis" of FM seems to progress to arthritic pathology. I say this because many people with FM complain consistently of stiffness, tendon shrinkage, muscular rigidity and shortening and disk herniation. That is: FM can worsen over time. Analgesics of any type can contribute to this progression if the person does not invest in physical exercise.

Some recent studies are showing that FM (as well as ME) involve chronic glial activation resulting in a low grade inflammatory state mainly involving TNF-a and IL-8. The link between FM and osteoarthritis has not been well explored and few physicians recommend Glucosamine sulphate (Glcn) for FM. I have recommended that physicians prescribe or recommend glucosamine in FM to reduce glial activation, partly to prevent the develoment of osteoarthritis but also to reduce pain. In addition glucosamine reduces LPS induced microglial activation - in turn reducing sympathetic NS mediated symptoms.